A decade ago, the Institute of Medicine found that up to 98,000 people a year die from medical errors in U.S. hospitals. Far less attention has been focused on safety issues in doctors' offices and other so-called ambulatory care settings -- that is, medical offices serving patients who mostly walk in and out -- where most healthcare is delivered.
Yet medical errors are also common in ambulatory care, and the Centers for Disease Control recently mounted a campaign to publicize how unsafe injection, infusion, and medication vial practices at clinics jeopardize patients.
According to a recent article in the American Journal of Infection Control, more than 100,000 people have been accidentally exposed to the hepatitis virus over the past 10 years because of these unsafe practices. As a result, more than 500 patients contracted either hepatitis B (HBV) or hepatitis (HCV) -- both very serious diseases.
Among the chief reasons for these outbreaks are the re-use of syringes with multiple patients; contamination of medication vials or IV bags after having been accessed by a used syringe or needle; failure to follow basic injection safety practices; and inappropriate care or maintenance of finger stick devices and glucometers between use on multiple patients. Other safety issues include the use of medications past their effective date, unsafe storage of multi-dose vials between uses, and the preparation of IV solutions hours ahead of use.
Among the examples of ambulatory-care safety problems given in the article:
In 2002, nearly 100 Nebraska hematology oncology clinic patients contracted HCV after a health care worker responsible for medication infusions routinely used the same syringe and needle from a HCV-positive patient's blood draw to obtain saline flush solution from an IV bag.
One of the most recent HCV outbreaks occurred at an endoscopy center in Nevada in 2008 because of unsafe injection practices involving reusing syringes and sharing single-use medication vials between patients. This outbreak received significant media attention because, in part, of the fact that 63,000 persons were identified as being at potential risk for acquiring hepatitis. More than 12,000 patients have been tested to date, and at least 115 patients have been found to be infected with HCV.
Worried yet? You should be, because this is undoubtedly just the tip of the iceberg. The CDC is so concerned that it's conducting a broad educational campaign with the Safe Injection Practices Coalition that targets healthcare providers. Among other things, the CDC is transmitting a video to doctors' and nurses' smart phones via Epocrates, a software-based service for mobile devices that around 40 percent of U.S. physicians use for drug information and other clinical content. The video features a breast cancer patient who, along with 98 other patients, contracted hepatitis C during chemotherapy because of an oncology clinic's failure to follow safe injection practices.
Injections are only one aspect of outpatient safety. There are also uncounted adverse drug events (ADEs) outside of hospitals. A seven-year-old study by the Center for Information Technology Leadership estimated there are about 38 ADEs per year for each ambulatory care provider in the U.S. Electronic prescribing with drug interaction alerts and other clinical decision support tools could prevent 14 of them, per the CITL study. In 2003, that represented the elimination of more than 2 million drug errors annually.
Aside from the threats to patient safety, these ambulatory-care errors cost a lot of money. But, despite the examples given above, healthcare providers rarely accept responsibility for their mistakes. So it will be as difficult to reduce medical errors in ambulatory care as in hospital care.
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